Spine Plain Films Research Articles

131. Sagittal profile modifications in vertebral body tethering (VBT) versus posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS)

<h3>BACKGROUND CONTEXT</h3> Sagittal alignment is integral to a patient's quality of life. Posterior spinal fusion (PSF) is currently the standard for correcting adolescent idiopathic scoliosis (AIS). Vertebral body tethering (VBT) is a fusionless growth modulating surgical technique used to treat AIS. It relies on the Hueter-Volkmann Law. Indications for this procedure include patients who have coronal curves up to 50°, growth remaining, and no excessive thoracic kyphosis. VBT has been shown to have good coronal plane deformity correction. There have been fewer examinations of the sagittal effects of VBT. <h3>PURPOSE</h3> To determine if VBT is a non-inferior treatment for correction of AIS with regard to sagittal alignment compared to PSF. <h3>STUDY DESIGN/SETTING</h3> Multicenter retrospective cohort study. <h3>PATIENT SAMPLE</h3> Patients with AIS who underwent correction surgeries with LIV in the lumbar spine from 2013 to 2021 with pre- and minimum two-year postoperative standing full spine plain films. <h3>OUTCOME MEASURES</h3> Sagittal vertical axis (SVA), cervical SVA (cSVA), pelvic tilt (PT), thoracic kyphosis (TK), cervical lordosis (CL), L4-S1 lordosis (L4L), T1 pelvic angle (TPA) and pelvic incidence lumbar lordosis mismatch (PI-LL). <h3>METHODS</h3> Radiographic analyses was completed with independent samples t-test with significance set to p <0.05. <h3>RESULTS</h3> A total of 99 patients were included, 49 VBT and 50 PSF. There were no differences in age or levels instrumented between groups. The VBT cohort Lenke class breakdown is 23% 1A, 13% 1C, 31% 3C. 18% 5C, and 15% 6C, while the PSF cohort consisted of 42% 1A, 6% 1B, 2% 2C, 2% 3B, 12% 3C, 2% 5B, 24% 5C, and 10% 6C. At Baseline, the VBT cohort had lower SVA (-0.7mm±3.7 vs 2.2mm±5.0, p=0.001), CL (-0.9°±18.2 vs 11.6°±12.8, p=0.001), L4-S1 Lordosis (20.7°±16.0 vs 41.6°±10.2, p=0.001), and higher cSVA (3.3mm±1.6 vs -0.95mm±3.1, p=0.001) than those who were fused. Postoperatively, VBT patients have an overall higher L4-S1 Lordosis (36.0°±10.1vs 18.3°±12.5, p=0.001), cSVA (3.4mm±1.4 vs -3.7mm±2.1, p=0.001), and lower CL (-4.3°±18.4 vs 7.0°±12.2, p=0.001). The PSF cohort had a larger change in cSVA (2.8mm±4.0 vs 0mm±1.6, p=0.001) from baseline to 2-year follow-up compared to VBT. No differences in the change of L4-S1 Lordosis (VBT 1.5°±12.3 vs 4.1°±10.9, p=0.3), TPA (VBT -1.6°±6.8 vs -1.4°±8.5, p=0.89), PT (VBT -0.5°±7.8 vs -1.9°±8.5, p=0.42), or PI-LL (0.2°±12.0 vs -0.5°±14.0, p=0.81) were observed. <h3>CONCLUSIONS</h3> VBT and PSF for AIS result in statistically similar changes in sagittal alignment parameters. The fact that we showed similar results comparing sagittal alignment in fusion and VBT groups indicates that VBT is non-inferior from a sagittal perspective. It is important to maintain sagittal alignment when correcting AIS. Future work can examine the long-term effect of VBT on sagittal alignment. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Cranio-Cervical Trauma Eidemiology, Classification, Diagnosis And Management

Objective: To provide an overview of current knowledge of the management of Cranio-Cervical (Occipito-cervical) injuries. Method: Literature search for new trends in the management of Cranio-cervical injuries. The article is divided into subheadings of Introduction, Epidemiology, pre-disposing factors and Anatomy of the Cranio-cervical junction including relevant surgical anatomy. NICE guidelines for management of cervical spine injuries and its recommendations are mentioned. This is followed by description of individual fractures, including their classification, clinical presentation and management. Recent advances in the management of individual fractures are mentioned with reference. The fractures covered are Occipital Condylar fractures (including Traumatic Atlanto-Occipital Dislocation), C1 Fractures (including Jefferson Fracture) and Odontoid fractures (including Hangman’s fracture) with brief description of surgical techniques to stabilize these fractures. Results: Cranio-cervical junction is a very tough construct and it requires very strong forces to result in occipito-cervical bony or ligamentous injuries. Cranio-cervical injuries must be suspected in high velocity injuries like RTAs and also in the elderly with neck pain and stiffness following a fall. Since Conventional cervical spine plain films can miss injuries in this region, there is need for a high index of suspicion as elaborated by NICE guidelines. There are new trends in the surgical management of Jefferson’s fractures (Posterior osteosynthesis) and Hangman’s fractures of C2 (Anterior approach better) Conclusion: Cranio-cervical injuries constitute a significant proportion of high velocity trauma and can be missed. There is a need for high index of suspicion in such patients. Recent trends seem to favour surgical management of these injuries even in the elderly. Aim should be early surgical fixation wherever possible even in elderly patients, if there is no significant co-morbidity or contraindication for surgery.

Sensitivity of plain radiography for pediatric cervical spine injury.

Pediatric patients with suspected cervical spine injuries (CSI) often receive a computed tomography (CT) scan as an initial diagnostic imaging test. While sensitive, CT of the cervical spine carries significant radiation and risk of lethal malignant transformation later in life. Plain radiographs carry significantly less radiation and could serve as the preferred screening tool, provided they have a high functional sensitivity in detecting pediatric patients with CSI. We hypothesize that plain cervical spine radiographs can reliably detect pediatric patients with CSI and seek to quantify the functional sensitivity of plain radiography as compared to CT. We analyzed data from the NEXUS cervical spine study to assess the sensitivity of plain radiographs in the evaluation of CSI. We identified all pediatric patients who underwent plain radiographic imaging, and all pediatric patients found to have CSI. We then determined the sensitivity of plain radiographs in detecting pediatric patients with CSI. We identified 44 pediatric patients with CSI in the dataset with age ranging from 2 to 18years old. Thirty-two of the 44 pediatric patients received cervical spine plain films as a part of their workup. Plain films were able to identify all 32 pediatric patients with CSI to yield a sensitivity of 100% in detecting injury victims (95% confidence interval 89.1-100.0%). Plain radiography was highly sensitive for the identification of CSI in our cohort of pediatric patients and is useful as a screening tool in the evaluation of pediatric CSI.

Flexion-Extension Cervical Spine Plain Films Compared with MRI in the Diagnosis of Ligamentous Injury

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 +/- 10.2, Glasgow Coma Scale was 13.8 +/- 3.5, lactate 2.2 +/- 1.7 mmol/L, and hospital stay of 8 +/- 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

Utilization and costs of lumbar and full spine radiography by Ontario chiropractors from 1994 to 2001

Background context In Ontario, chiropractors see one-third of patients who seek care for low back pain. Previous studies suggest that chiropractors have high utilization rates of lumbar and full spine radiography. There has been a proliferation of evidence-based guidelines recommending that plain film radiography be used only to assess high-risk patients with low back pain. Evidence for the use of full spine radiography, except for the evaluation of scoliosis is lacking. It is uncertain what impact the growing evidence against their use has had on radiography utilization by Ontario chiropractors. Purpose To describe the annual costs and use of lumbar and full spine plain film radiography among Ontario chiropractors between 1994 and 2001. Study design/setting Time-trend analysis of radiography utilization by Ontario chiropractors. Patient sample Chiropractic claims data submitted to the Ontario Health Insurance Plan or the Workplace Safety & Insurance Board from 1994/1995 to 2000/2001. Outcome measures Change in the annual cost and proportion of claimants receiving lumbar and full spine radiography. Methods Time-trend analysis of chiropractic claims submitted to the Ontario Health Insurance Plan (OHIP) or Workplace Safety & Insurance Board (WSIB) from 1994/1995 to 2000/2001 fiscal years. Results During the 7-year period, the proportion of OHIP claimants receiving lumbar spine radiography decreased from 4.54% to 3.25% and for full spine radiography from 3.87% to 3.04%. For WSIB claimants, lumbar spine radiography deceased from 6.49% to 3.30% of claimants and full spine radiography from 1.51% to 0.94%. OHIP payments for lumbar spine radiography decreased 12.7% to $562,944, whereas full spine radiography payments decreased 5.3% to $1,071,408. WSIB lumbar and full spine radiography payments decreased 44.2% and 34.3% to $31,202 and $11,713 respectively. Conclusions Claims data from the two largest third-party payers of chiropractic services in Ontario, suggest that lumbar and full spine radiography, and their associated costs decreased steadily between 1994 and 2001.

Is The Lateral Cervical Spine Plain Film Obsolete?

Is The Lateral Cervical Spine Plain Film Obsolete?

Foraminal Stenosis With Radiculopathy From a Cervical Disc Herniation in a 33-Year-Old Man Treated With Flexion Distraction Decompression Manipulation

Objective The purpose of this report was to describe the use of Cox flexion distraction decompression manipulation on a patient with radiculopathy from a C6/C7 disc herniation. Clinical Features A 33-year-old man complained of severe neck pain and spasms, pain radiating down his left arm and upper back, and associated numbness in his fingers. Cervical spine plain film radiographs showed mild C6/C7 osseous degenerative changes. Cervical magnetic resonance imaging revealed a moderate-sized left posterolateral disc herniation at C6/C7 causing severe foraminal stenosis. Intervention and Outcome Treatment consisted of Cox flexion distraction decompression manipulation and adjunctive physiotherapy modalities. The patient was treated a total of 15 times over a period of 10 weeks. Subjective findings using a pain scale and objective examination findings supported a good clinical outcome. At 2-year follow-up, subjective and objective findings remained stable. Conclusion This study reports Cox flexion distraction decompression manipulation and physiotherapy modalities showed good subjective and objective clinical outcomes for this patient.

Is The Lateral Cervical Spine Plain Film Obsolete?

The objective of this study was to determine the utility of a lateral cervical spine plain film in the evaluation of blunt trauma patients. We prospectively evaluated blunt trauma patients from February 2004 to September 2006 who had both a lateral cervical spine (LCS) film and a computed tomography of the cervical spine (CTC), comparing the diagnostic accuracy of the LCS to the CTC. There were 1004 patients who met inclusion criteria. Eighty-four patients had a cervical spine fracture while 920 patients had no fracture on CTC. Of the 84 patients with fractures by CTC, 68 had a negative or incomplete LCS. Of the 920 negative CTC, there were 7 false positive LCSs. LCS compared with CTC showed a sensitivity of 19% (16/84) and positive predictive value of 69.6% (16/23). Of the 981 negative or incomplete LCS films, 96.9% were incomplete (951/981). Of the seven patients with a false positive LCS (negative CTC), none was subsequently found to have a cervical spine fracture on further evaluation. Elimination of the LCS would result in charge savings of $265,056.00 (LCS charges with interpretation, $264 each) and increase patient safety by eliminating error. LCS has no value as a screening tool in the blunt trauma patient since most are either inaccurate or incomplete. It should be eliminated from the Advanced Trauma Life Support algorithm, and CTC should receive emphasis as the diagnostic gold standard.

QS249. Is the Lateral Cervical Spine Plain Film Obsolete

Background: Physical examination has been shown to be extremely inaccurate in cervical spine evaluation in trauma activation patients as compared to the “gold standard” of computed tomography of the cervical spine (CTC). The objective of the current study is to determine the utility of a lateral cervical spine plain film (the recommended initial approach by ATLS) in the evaluation of blunt trauma patients. Methods: We prospectively evaluated blunt trauma patients from February 2004 to September 2006.

Should Plain Films of the Lumbar Spine be Taken in the Posterior-to-Anterior or Anterior-to-Posterior Position? A Study Using Decision Analysis

Objective The objective of this study was to mathematically propose the best position for frontally oriented lumbar spine radiographs. Methods Decision analysis with a decision tree was used in this study. Factors used in the analysis were radiation dose, ease of implementation, image quality, cost, and patient comfort. Data on these factors were gathered by reviewing the literature. Results Radiation dose was found to be the only factor with significant differences between the posterior-to-anterior (PA) position and the anterior-to-posterior (AP) position, and PA films gave lower doses to sensitive organs as compared with AP films. There is also some evidence that PA films show better overall image quality as compared with AP films. Conclusions Based on the information used in this study, lumbar spine plain film radiographs should be obtained in the PA position.

Developmental Anomalies of the Cervical Spine in Patients With Fibrodysplasia Ossificans Progressiva Are Distinctly Different From Those in Patients With Klippel-Feil Syndrome

A radiographic analysis of the cervical spine of 70 patients diagnosed with fibrodysplasia ossificans progressiva (FOP) and 33 diagnosed with Klippel-Feil (KF) syndrome was conducted. The objectives of this study were to describe cervical spine abnormalities in patients with FOP, to compare and contrast those findings with the malformations in patients with KF syndrome, and to examine the possible etiology of these abnormalities. Congenital features of diseases often provide seminal clues to underlying etiology and developmental pathways. While progressive metamorphosis of connective tissue to heterotopic bone is the most dramatic and disabling feature of FOP, less severe congenital anomalies of the skeleton are also present. Vertebral fusions observed in KF are consistent with defects in embryonic segmentation. The cervical spine plain films of 70 FOP patients and 33 KF patients with documented congenital abnormalities were reviewed. Generalized neck stiffness and decreased range of motion were noted in most children with FOP. In the FOP patient group, characteristic anomalies, including large posterior elements, tall narrow vertebral bodies,and fusion of the facet joints between C2 and C7, were observed. Most notably, these characteristic anomalies of the cervical spine in patients with FOP were distinctly different from those of 33 patients with KF that were examined but were strikingly similar to those seen in mice with homozygous deletions of the gene-encoding noggin, a bone morphogenetic protein (BMP) antagonist. FOP patients exhibit a characteristic set of congenital spine malformations. While the noggin gene (NOG) is not mutated in patients who have FOP, these findings extend a growing body of evidence implicating overactivity of the BMP signaling pathway in the molecular pathogenesis of FOP.

Occupational and personal factors associated with acquired lumbar spondylolisthesis of urban taxi drivers

Aims: To investigate the occupational and personal factors associated with lumbar spondylolisthesis in taxi drivers. Methods: Cross-sectional analysis of the baseline data from the Taxi Drivers’ Health Study cohort. Information...

New Clinical Rule Highly Sensitive for Cervical Spine Injuries

The highly publicized NEXUS criteria for excluding the need for cervical spine plain film radiography have a sensitivity of 99.4 percent but a

BACK PAIN IN A SOCCER PLAYER

HISTORY - A 21 year old college soccer player presented with a three week history of low back pain. During warm-up, he reported doing abdominal strengtheming exercises with his hips flexed and lower extremities elevated. As part of the exercise, his teammate pushed his legs to the right. He immediately felt a sharp pain that resolved within a few minutes. A week later, during an intra-squad scrimmage, he twisted his back. After several days, his back pain radiated down his left lower extremity and alternated intermittently to his right lower extremity with associated numbness and tingling. The symptoms worsened after activity and the pain persisted despite Aleve, rest, stretching, and back exercises. There was no history of back pain, trauma, or prior injuries. PHYSICAL EXAMINATION - General examination revealed normal stance and gait. Examination of the lumbar spine revealed mild scoliosis. Tenderness of the right lower paraspinals were present. Range of motion of his back was 75% of full flexion, lateral bending, and lateral rotation. Full extension was present. He had pain with back flexion and improvement of pain with back extension. Pain was also elicited with hip flexion, extension, and abduction. Popliteal angles bilaterally were 10 degrees. Ely's test was 7 inches bilaterally and caused anterior pelvic tilting with increased lumbar lordosis. Valsalva maneuver and straight leg raise test were negative bilaterally. There was full strength of lower extremities with intact sensation to pinprick. The reflexes were 1 + and symmetrical at the patellas, medial hamstrings, and ankles. DIFFERENTIAL DIAGNOSIS: Lumbar radiculopathy Discogenic low back pain Lumbar strain/sprain TEST AND RESULTS: Lumbar spine plain film: AP/Lateral/Oblique: -normal lumbosacral spine MRI of lumbar spine: partially lumbarized S1 rudimentary disc at the S1/S2 level stress fractures of the pedicles of L4-fracture extend through the inferior cortex and approach the superior cortex no lumbar disc herniation or nerve root impingement FINAL/WORKING DIAGNOSIS: Bilateral pedicle fracture of L4 TREATMENT: Back brace NSAIDs Physical therapy with stretching, strengthening, lumbopelvic stabilization and balance exercises Hold from contact sports

Can chest and abdominal trauma CT eliminate the need for plain films of the spine? – Experience with 329 multiple trauma patients

Purpose: To compare the accuracy of spine plain films with chest and abdominal trauma CT in detection of spine fractures. Methods: The study prospectively enrolled 329 multiple trauma patients. Of these, 38 patients had both chest CT for trauma and thoracic spine plain films, and 87 patients had both abdominal CT for trauma and lumbar spine plain films. Results: Of the fractures visible at either chest trauma CT or thoracic spine plain film examination, all were diagnosed on CT and 62 % on plain films. Of fractures visible at either abdominal trauma CT or lumbar spine plain films, 94 % were diagnosed on CT and 67 % on plain films. The one false negative CT involved an articular process fracture, which was visible but not mentioned, in a patient with a sacral fracture. Conclusion: Evaluation of the digital scout images and bone windows when a patient has chest and abdominal trauma CT appears to be as accurate as thoracic and lumbar spine plain films in the evaluation of spinal trauma.

Treatment of cervical radiculopathy with flexion distraction

<h2>Abstract</h2> <b>Objective:</b> To discuss the nonsurgical treatment of a cervical disk herniation with flexion distraction manipulation. <b>Clinical Features:</b> A case study of cervical disk syndrome with radicular symptoms is presented. Magnetic resonance imaging revealed a large C5-C6 disk herniation. Degenerative changes at the affected level were demonstrated on cervical spine plain film radiographs. <b>Intervention and Outcome:</b> The patient received treatment in the form of flexion distraction manipulation and adjunctive therapies. A complete resolution of the patient's subjective complaints was achieved. <b>Conclusion:</b> Flexion distraction has been a technique associated with musculoskeletal conditions of the lumbar spine. Flexion distraction applied to the cervical spine might be an effective therapy in the treatment of cervical disk herniations. Although further controlled studies are needed, treatment of cervical disk syndromes with flexion distraction might be a viable form of conservative care.

Treatment of cervical radiculopathy with flexion distraction

Objective: To discuss the nonsurgical treatment of a cervical disk herniation with flexion distraction manipulation. Clinical Features: A case study of cervical disk syndrome with radicular symptoms is presented. Magnetic resonance imaging revealed a large C5-C6 disk herniation. Degenerative changes at the affected level were demonstrated on cervical spine plain film radiographs. Intervention and Outcome: The patient received treatment in the form of flexion distraction manipulation and adjunctive therapies. A complete resolution of the patient's subjective complaints was achieved. Conclusion: Flexion distraction has been a technique associated with musculoskeletal conditions of the lumbar spine. Flexion distraction applied to the cervical spine might be an effective therapy in the treatment of cervical disk herniations. Although further controlled studies are needed, treatment of cervical disk syndromes with flexion distraction might be a viable form of conservative care.

Cervical spine instability: clearance using dynamic fluoroscopy

Purpose Cle aring the cervical spine in a multiply injured trauma patient is a dilemma because clinical examination for ligamentous instability cannot be performed, and the standard cervical spine series can miss isolated ligamentous injury. Static flexion/extension views are unsafe, as the obtunded patient has no protective reflexes and cannot complain of pain during the exam. This results in a need for prolonged spinal immobilization and its attendant complications. Dynamic fluoroscopy may be useful in the detection of otherwise occult injuries. Methods We performed a prospective study of a cervical spine clearance algorithm incorporating dynamic fluoroscopy with flexion/extension views. Inpatient records over a 3-year period were reviewed. Patient demographic data, results of cervical spine films and fluoroscopic exams, interventions based on positive results, and missed injuries were recorded. Results One hundred ten patients with normal spine plain films underwent dynamic fluoroscopy with flexion and extension views of the cervical spine. The average Glasgow Coma Score was 9.2 and the average revised Trauma Score was 9.5. Nine patients had evidence of cervical instability on exam. Six of these were deemed stable by the orthopedic or neurosurgical spine consultants, and these patients had their hard collars removed. One patient with positive findings had cervical immobilization with hard collar continued, a second had halo placement, and a third underwent spinal fusion for atlanto-occipital disassociation. No patients undergoing dynamic fluoroscopy were subsequently found to have missed cervical spine injury. Conclusions With our protocol, 3 patients had significant cervical instability that would have been missed without dynamic fluoroscopy. Given the significant medical and legal ramifications of missed cervical spine injury and the benefits of early removal of cervical collars, more widespread use of dynamic fluoroscopy of the cervical spine is warranted.

Commentary

Cle aring the cervical spine in a multiply injured trauma patient is a dilemma because clinical examination for ligamentous instability cannot be performed, and the standard cervical spine series can miss isolated ligamentous injury. Static flexion/extension views are unsafe, as the obtunded patient has no protective reflexes and cannot complain of pain during the exam. This results in a need for prolonged spinal immobilization and its attendant complications. Dynamic fluoroscopy may be useful in the detection of otherwise occult injuries.We performed a prospective study of a cervical spine clearance algorithm incorporating dynamic fluoroscopy with flexion/extension views. Inpatient records over a 3-year period were reviewed. Patient demographic data, results of cervical spine films and fluoroscopic exams, interventions based on positive results, and missed injuries were recorded.One hundred ten patients with normal spine plain films underwent dynamic fluoroscopy with flexion and extension views of the cervical spine. The average Glasgow Coma Score was 9.2 and the average revised Trauma Score was 9.5. Nine patients had evidence of cervical instability on exam. Six of these were deemed stable by the orthopedic or neurosurgical spine consultants, and these patients had their hard collars removed. One patient with positive findings had cervical immobilization with hard collar continued, a second had halo placement, and a third underwent spinal fusion for atlanto-occipital disassociation. No patients undergoing dynamic fluoroscopy were subsequently found to have missed cervical spine injury.With our protocol, 3 patients had significant cervical instability that would have been missed without dynamic fluoroscopy. Given the significant medical and legal ramifications of missed cervical spine injury and the benefits of early removal of cervical collars, more widespread use of dynamic fluoroscopy of the cervical spine is warranted.